Mission: “To provide affordable housing to low income seniors who wish to maintain independent
living in a safe and secure environment.”
Willow Point Supportive Living Society
Rental Application
Please read and complete all pages as fully as possible.
- Willow Point Supportive Living Society:
a)is a non-smoking facility,
b)provides housing to low income seniors
c)may allowpets upon prior approval
d)may allow scooters upon prior approval
- Willow Point Supportive Living Society provides an “Independent Living” facility. Applicant(s) must be functionally independent. This Society does not provide any personal assistance to residents to remain independent. If, following an assessment by the Societies staff, it is determined that the resident:
a)has personal care needs beyond what the Society is able to provide, or
b)place themselves or others at risk, or
c) interferes with the operation of the facility or
d)harasses or interferes with staff or other residents reasonable quiet enjoyment,
then
Willow Point Supportive Living Society can terminate the tenancy agreement.
- SPONSOR means “any person or persons who agrees to assume responsibility for a resident should that resident be no longer able to reside with Willow Point Supportive Living Society for any reason.
- In the event of the termination of the tenancy agreement when the resident is deemed no longer safe to live in the complex, the resident, residents sponsor or the residents family agree to immediately comply inrelocating the resident.
- Rental rates are not subsidized and subject to periodic legal rent increases as stipulated under the Residential Tenancy Act and may change from time to time. Residents of low income may qualify under the SAFER (Shelter Assistance for Elderly Renters) program for a rebate of a portion of their rent by applying to B.C. Housing.(
- Rental agreements are on a month-to-month basis and as such, one full months notice from the next date rent is due is required upon leaving the unit, including transition to a care facility or upon death. Unpaid rent will be paid by the family, the sponsor or the estate.
- Applications may be submitted at any time and will be placed on a waiting list. The application is only good for one year from the date of application. Applicants must then apply again or be stricken from the list.
APPLICATION:
NAME applicant 1 ______BIRTHDATE______
NAME applicant 2 ______BIRTHDATE______
ADDRESS______P.C. ______PHONE NO.______
email address: ______
LENGTH OF RESIDENCY IN CAMPBELL RIVER ______IN B.C.______
NEXT OF KIN name ______RELATIONSHIP______
ADDRESS______P.C.______PHONE ______
email address: ______
NEXT OF KIN______RELATIONSHIP______
ADDRESS______P.C.______PHONE ______
email address: ______
For more children or next of kin information, use a separate paper.
State name and address of person(s) (sponsor) who agrees to assume responsibility for securing other accommodation for you, should your personal care needs become beyond what the Society is able to provide. In the event you have no one, please discuss this with your Health Authority Case Manager.
SPONSOR NAME______PHONE NO.______Relationship______
ADDRESS______P.C.______POWER OF ATTORNEY Yes__ No__
email address: ______
SPONSOR NAME______PHONE NO.______Relationship ______
ADDRESS______P.C. ______POWER OF ATTORNEY Yes__ No__
email address: ______
ANY HEALTH ISSUES WE SHOULD BE AWARE OF______
______
DO YOU SMOKE? ______
DOCTOR’S NAME______PHONE NO.______
SPOUSE/PARTNER’S HEALTH______DOES YOUR PARNER SMOKE?______
DOCTOR’S NAME______PHONE NO.______
DECLARATION OF ASSETS AND INCOME:
MONTHLY or ANNUAL INCOME(TOTAL IF TWO APPLICANTS)______
DO YOU OWN A MOTOR VEHICLE Y / N Make______LICENCE NO______
RESIDENCY HISTORY: Please list your addresses for the past two years.
ADDRESS 1: ______P.C. ______DATE FROM ______TO ______
OWNER/MANAGER ______PHONE NO. ______
AMOUNT OF RENT PAID $______
ADDRESS 2:______P.C. ______DATE FROM ______TO ______
OWNER/MANAGER ______PHONE NO. ______
AMOUNT OF RENT PAID $______
HAVE YOU EVER BEEN UNDER NOTICE TO VACATE?______
IF YES, WHEN?______
IF YES, WHAT WERE THE CIRCUMSTANCES? ______
REASONS FOR WANTING TO LEAVE PRESENT ACCOMODATION ______
REFERENCES:
NAME______PHONE NO.______
ADDRESS______P.C. ______RELATIONSHIP ______
email address: ______
NAME______PHONE NO.______
ADDRESS______P.C.______RELATIONSHIP ______
email address: ______
Suite preference: (first and second choice) one bedroom____ two bedroom______patio home_____wheelchair access______
(please check wheelchair access if you require a wheelchair currently or may require one soon)
DECLARATION OF APPLICANT:
I fully understand that this is not a contract and does not bind either party. The above information is full, true and complete to the best of my knowledge. I have no objections to inquiries for the purpose of verifying the facts as stated. I am aware that I must present verification or proof of income prior for board approval of my application. I/We agree to abide by the Rules and Regulations of the Willow Point Supportive Living Society, as now in force or as hereafter amended.
Please note that upon your being accepted as a resident and before you move in, you will be required to pay a deposit equal to ½ (one half) of one month’s rent plus the first month’s rent. Monthly rent is always paid in advance on the first day of each month.
You are responsible for the electricity, the telephone, and the cable T.V. in your unit. If you are renting a patio home, you are also responsible for the natural gas for hot water and heat, which averages about $150.00 per month year around.
As we have a long waiting list, your application will be kept on file for a period of one year. If you have not heard from us in that time, you must re-apply.
(Signature of applicant(s)
SIGNED ______DATE ______
SIGNED ______DATE ______
(Signature of Sponsor(s)
SIGNED ______DATE ______
SIGNED ______DATE ______
THIS SPACE FOR OFFICE USE ONLY
DATE APPLICATION RECEIVED: ______
INTERVIEWER: ______DATE OF INTERVIEW______
INTERVIEWER: ______DATE OF INTERVIEW______
COMMITTEE RECOMMENDATION:______
______
Page 1 of 4